Download PDF
Laryngorhinootologie 2021; 100(08): 610-617
DOI: 10.1055/a-1381-8286
Übersicht

Postoperative Hypokalzämie – die häufigste Komplikation der endokrinen Chirurgie der Halsregion: Akutes Management

Postoperative hypocalcemia – the most common complication of endocrine head and neck surgery: acute management
Anne Lammert
1   Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
,
Kai Nowak
2   Klinik für Allgemein-, Gefäß- und Thoraxchirurgie, RoMed Klinikum, Rosenheim, Germany
,
Roland Weber
3   Medizinische Klinik II, RoMed Kliniken, Rosenheim, Germany
,
Nicole Rotter
1   Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Halschirurgie, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
,
Sebastian Schölch
4   Chirurgische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
,
Bernhard K. Krämer
5   V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
,
Alexander Lammert 
5   V. Medizinische Klinik, Universität Heidelberg, Universitätsmedizin Mannheim, Mannheim, Germany
6   Apherese- und Dialysezentrum Grünstadt, Praxis für Diabetes, Stoffwechsel und Nierenerkrankungen, Grünstadt, Germany
› Author Affiliations
› Further Information
Also available at
    Permissions and Reprints

Zusammenfassung

Hintergrund In Deutschland sind jährlich ca. 8000 Patienten nach Eingriffen an Schilddrüse, Nebenschilddrüse und Larynx von einem behandlungsbedürftigen postoperativen Hypoparathyreoidismus betroffen. Die Patienten leiden im Akutstadium der Hypokalzämie an Parästhesien und nicht selten auch über viele Jahre hinweg unter der Angst vor einem erneuten körperlichen Kontrollverlust bei schweren postoperativen Tetanien.

Fragestellung/Ziel Ziel dieser Arbeit ist es, für die Wichtigkeit des Managements des postoperativen Hypoparathyreoidismus in der endokrinen Chirurgie der Halsregion zu sensibilisieren, einen praktikablen Diagnostikpfad aufzuzeigen und so die effektive Therapie zu ermöglichen.

Material und Methode Narratives Review mit Auswertung und Diskussion von relevanten klinischen Originalarbeiten und Expertenempfehlungen.

Ergebnisse und Diskussion Die frühzeitige postoperative Diagnosestellung nach Eingriffen im Halsbereich mittels Bestimmung von Kalzium und Parathormon ermöglicht den rechtzeitigen Therapiebeginn. Aktives Vitamin D sichert dabei die Resorption von Kalzium, sodass nur eine kombinierte Gabe von Vitamin D und Kalzium in der Lage ist, den postoperativen Kalziumabfall zu mitigieren oder ganz zu verhindern.

Schlussfolgerung Eine Arbeitsanweisung (SOP) zur Diagnostik und Therapie der postoperativen Hypokalzämie sollte in jeder Klinik etabliert werden. Ein entsprechender Entwurf wurde in die Arbeit aufgenommen, damit Diagnose- und Therapiepfad effektiv an lokale Gegebenheiten angepasst werden können.

Abstract

Background In Germany, 8000 patients are affected by postoperative hypoparathyroidism per year following surgery of the thyroid gland, parathyroidal glands and the larynx. Patients do not only suffer from paresthesia in the acute phase of this complication, but are also adversely affected by the fear of loss of control following episodes of tetany even years after the first episode.

Objectives Discussion of a diagnostic pathway and presentation of a management pathway for postoperative hypocalcemia.

Methods Narrative review, analysis and discussion of current literature and expert recommendations.

Results Early determination of calcium and parathyroid hormone allows timely diagnosis and treatment of postoperative hypoparathyroidism. Active vitamin D is pivotal for the resorption of calcium. Only the combined treatment with active vitamin D and calcium can mitigate or prevent the postoperative drop of calcium levels.

Conclusions A standard operating procedure (SOP) for postoperative hypoparathyroidism should be implemented in every surgical department. An SOP for diagnosis and treatment of postoperative hypoparathyroidism is proposed for institutional individualization and implementation.

Schlüsselwörter

Hypokalzämie - Hypoparathyreoidismus - endokrine Chirurgie - Schilddrüsenchirurgie - Laryngektomie

Key words

hypocalcemia - hypoparathyroidism - endocrine surgery - surgery of thyroid gland - laryngectomy

Supplement



Publication History

Received: 11 September 2020

Accepted: 01 February 2021

Article published online:
02 March 2021

© 2021. Thieme. All rights reserved.

Georg Thieme Verlag KG
Rüdigerstraße 14, 70469 Stuttgart, Germany

 

  • Literatur

  • 1 Adams J, Andersen P, Everts E. et al. Early Postoperative Kalzium Levels as Predictors of Hypocalcemia. Laryngoscope 1998; 108 (12) 1829-1831
    CrossrefPubMedGoogle Scholar
  • 2 Alía P, Moreno P, Rigo R. et al. Postresection Parathyroid Hormone and Parathyroid Hormone Decline Accurately Predict Hypocalcemia After Thyroidectomy. Am J Clin Pathol 2007; 127 (04) 592-597
    CrossrefPubMedGoogle Scholar
  • 3 Barczynski M, Cichon S, Konturek A. Which Criterion of Intraoperative iPTH Assay Is the Most Accurate in Prediction of True Serum Kalzium Levels After Thyroid Surgery?. Langenbecks Arch Surg 2007; 392 (06) 693-698
    CrossrefPubMedGoogle Scholar
  • 4 Bentrem DJ, Rademaker A, Angelos P. Evaluation of Serum Kalzium Levels Predicting Hypoparathyroidism After Total/Near-Total Thyroidectomy or Parathyroidectomy. Am Surg 2001; 67 (03) 249-251
    CrossrefPubMedGoogle Scholar
  • 5 Cannizzaro MA, Okatyeva V, Lo Bianco S. et al. Hypocalcemia After Thyroidectomy: iPTH Levels and iPTH Decline Are Predictive? Retrospective Cohort Study. Ann Med Surg (Lond) 2018; 30: 42-45
    CrossrefPubMedGoogle Scholar
  • 6 Chang JW, Park KW, Jung SN. et al. The Most Reliable Time Point for Intact Parathyroid Hormone Measurement to Predict Hypoparathyroidism After Total Thyroidectomy with Central Neck Dissection to Treat Papillary Thyroid Carcinoma: A Prospective Cohort Study. Eur Arch Otorhinolaryngol 2020; 277 (02) 549-558
    CrossrefPubMedGoogle Scholar
  • 7 Chia SH, Weisman RA, Tieu D. et al. Prospective Study of Perioperative Factors Predicting Hypocalcemia After Thyroid and Parathyroid Surgery. Arch Otolaryngol Head Neck Surg 2006; 132 (01) 41-45
    CrossrefPubMedGoogle Scholar
  • 8 Duplay Q, Riou J, Lesage C. et al Can postoperative calcemia kinetics predict the risk of hypocalcemia for the management of parathyroid adenoma in ambulatory surgery?. J Visc Surg 2020; 157 (03) 175-182 DOI: 10.1016/j.jviscsurg.2019.12.00.
    CrossrefPubMedGoogle Scholar
  • 9 Edafe O, Balasubramanian SP. Incidence, prevalence and risk factors for post-surgical hypocalcaemia and hypoparathyroidism. Gland Surg 2017; 6 (Suppl. 01) S59-S68
    CrossrefPubMedGoogle Scholar
  • 10 Edafe O, Sandler LM, Beasley N. et al Systematic review of incidence, risk factors, prevention and treatment of post-laryngectomy hypoparathyroidism. Eur Arch Otorhinolaryngol Online ahead of print 2020; DOI: 10.1007/s00405-020-06213-2.
    CrossrefPubMedGoogle Scholar
  • 11 Filho EBY, Machry RV, Mesquita R. et al. the Timing of Parathyroid Hormone Measurement Defines the Cut-Off Values to Accurately Predict Postoperative Hypocalcemia: A Prospective Study. Endocrine 2018; 61 (02) 224-231
    CrossrefPubMedGoogle Scholar
  • 12 Ghigo E. Vitamin D in Clinical Medicine. In Giustina A, Bilezikian JP. (Hrsg) Frontiers of Hormone Research, Band 50. Freiburg im Breisgau: Karger; 2018
    Google Scholar
  • 13 Grzegory A, Pomorski L. Perioperative Kalzium and Vitamin D Supplementation in Patients Undergoing Thyroidectomy – Literature Review. Pol Przegl Chir 2018; 90 (04) 46-50
    CrossrefPubMedGoogle Scholar
  • 14 Güllüoglu BM, Manukyan MN, Cingi A. et al. Early Prediction of Normocalcemia After Thyroid Surgery. World J Surg 2005; 29 (10) 1288-1293
    CrossrefPubMedGoogle Scholar
  • 15 Hansen KE, Jones AN, Lindstrom MJ. et al. Do proton pump inhibitors decrease Kalzium absorption?. J Bone Miner Res 2010; 25: 2786-2795
    CrossrefPubMedGoogle Scholar
  • 16 Hermann M, Ott J, Promberger R. Kinetics of serum parathyroid hormone during and after thyroid surgery. Br J Surg 2008; 95 (12) 1480-1487
    CrossrefPubMedGoogle Scholar
  • 17 Husein M, Hier MP, Al-Abdulhadi K. et al. Predicting Kalzium Status Post Thyroidectomy with Early Kalzium Levels. Otolaryngol Head Neck Surg 2002; 127 (04) 289-293
    CrossrefPubMedGoogle Scholar
  • 18 Islam S, Al Maqbali T, Howe D. et al. Hypocalcaemia Following Total Thyroidectomy: Early Post-Operative Parathyroid Hormone Assay as a Risk Stratification and Management Tool. J Laryngol Otol 2014; 128 (03) 274-278
    CrossrefPubMedGoogle Scholar
  • 19 Kala F, Sarici IS, Ulutas KT. et al. Intact Parathormone Measurement 1 Hour After Total Thyroidectomy as a Predictor of symptomatic Hypocalcemia. Int J Clin Exp Med 2015; 8 (19) 18813-18818
    PubMedGoogle Scholar
  • 20 Khan AA, Koch C, Van Uum SHM. et al. Standards of Care for Hypoparathyroidism in Adults. Eur J Endocrinol 2018; 180 (03) P1-P22
    CrossrefPubMedGoogle Scholar
  • 21 Kolahdouzan M, Shahmiri SS, Hashemi SM. et al. Is Decline Rate of Intact Parathyroid Hormone Level a Reliable Criterion for Early Discharge of Patients After Total Thyroidectomy?. Iran J Otorhinolaryngol 2017; 29 (94) 239-246
    PubMedGoogle Scholar
  • 22 Lang BH, Yih PCL, Ng KK. A Prospective Evaluation of Quick Intraoperative Parathyroid Hormone Assay at the Time of Skin Closure in Predicting Clinically Relevant Hypocalcemia After Thyroidectomy. World J Surg 2012; 36 (06) 1300-1306
    CrossrefPubMedGoogle Scholar
  • 23 Lazard DS, Godiris-Petit G, Wagner I. et al. Early Detection of Hypocalcemia After Total/Completion Thyroidectomy: Routinely Usable Algorithm Based on Serum Kalzium Level. World J Surg 2012; 36 (11) 2590-2597
    CrossrefPubMedGoogle Scholar
  • 24 McCullough M, Weber C, Leong C. et al. Safety, Efficacy, and Cost Savings of Single Parathyroid Hormone Measurement for Risk Stratification After Total Thyroidectomy. Am Surg 2013; 79 (08) 768-774
    CrossrefPubMedGoogle Scholar
  • 25 Musholt TJ, Bockisch A, Clerici T. et al. Update of the S2k Guidelines: Surgical Treatment of Benign Thyroid Disease. Chirurg 2018; 89 (09) 699-709
    CrossrefPubMedGoogle Scholar
  • 26 Musholt TJ, Clerici T, Dralle H. et al. German Association of Endocrine Surgeons Practice Guidelines for the Surgical Treatment of Benign Thyroid Disease. Langenbecks Arch Surg 2011; 396 (05) 639-649
    CrossrefPubMedGoogle Scholar
  • 27 Nahas ZS, Farrag TY, Lin FR. et al. A Safe and Cost-Effective Short Hospital Stay Protocal to Identify Patients at Low Risk for the Development of Significant Hypocalcemia After Total Thyroidectomy. Laryngoscope 2006; 116 (06) 906-910
    CrossrefPubMedGoogle Scholar
  • 28 Palmhag D, Brydolf J, Zedenius J. et al A Single Parathyroid Hormone Measurement Two Hours After a Thyroidectomy Reliably Predicts Permanent Hypoparathyroidism. Scan J Surg 2020 [in press]
    PubMedGoogle Scholar
  • 29 Roh JL, Park C. Intraoperative parathyroid hormone assay for management of patients undergoing total thyroidectomy. Head Neck 2006; 28 (11) 990-997
    CrossrefPubMedGoogle Scholar
  • 30 Richards ML, Bingener-Casey J, Pierce D. et al. Intraoperative Parathyroid Hormone Assay: An Accurate Predictor of Symptomatic Hypocalcemia Following Thyroidectomy. Arch Surg 2003; 138 (06) 632-635
    CrossrefPubMedGoogle Scholar
  • 31 Saad RK, Boueiz NG, Akiki VC. et al. Rate of Drop in Serum Kalzium as a Predictor of Hypocalcemic Symptoms Post Total Thyroidectomy. Osteoporos Int 2019; 30 (12) 2495-2504
    CrossrefPubMedGoogle Scholar
  • 32 Sanabria A, Rojas A, Arevalo J. et al. Meta-analysis of Routine Kalzium/Vitamin D3 Supplementation Versus Serum Kalzium Level-Based Strategy to Prevent Postoperative Hypocalcaemia After Thyroidectomy. Br J Surg 2019; 106 (09) 1126-1137
    CrossrefPubMedGoogle Scholar
  • 33 Selberherr A, Scheuba C, Riss P. et al. Postoperative hypoparathyroidism after thyroidectomy: efficient and cost-effective diagnosis and treatment. Surgery 2015; 157: 349-353
    CrossrefPubMedGoogle Scholar
  • 34 Skelin M, Lucijanic T, Klaric DA. Factors Affecting Gastrointestinal Absorption of Levothyroxine: A Review. Clin ther 2017; 39 (02) 378-403
    CrossrefPubMedGoogle Scholar
  • 35 Stack BC, Bimston DN, Bodenner DL. et al. American Association of clinical endocrinologists and American College of endocrinology disease state clinical review: postoperative hypoparathyroidism – definitions and management. Endocrine Practice 2015; 21 (06) 674-685
    CrossrefPubMedGoogle Scholar
  • 36 Statistisches Bundesamt (Destatis). Gesundheit – Fallpauschalenbezogene Krankenhausstatistik (DRG-Statistik) Operationen und Prozeduren der vollstationären Patientinnen und Patienten in Krankenhäusern (4-Steller) 2019. Erscheinungsfolge: jährlich, Erschienen am: 30.10.2020, Artikelnummer: 5231401187014
    PubMedGoogle Scholar
  • 37 Suwannasarn M, Jongjaroenprasert W, Chayangsu P. et al. Single measurement of intact parathyroid hormone after thyroidectomy can predict transient and permanent hypoparathyroidism: a prospective study. Asian J Surg 2015; 40 (05) 350-356
    CrossrefPubMedGoogle Scholar
  • 38 Sywak MS, Palazzp FF, Yeh M. et al. Parathyroid Hormone Assay Predicts Hypocalcaemia After Total Thyroidectomy. ANZ J Surg 2007; 77 (08) 667-670
    CrossrefPubMedGoogle Scholar
  • 39 Vasher M, Goodman A, Politz D. Postoperative Kalzium Requirements in 6000 Patients Undergoing Outpatient Parathyroidectomy: Easily Avoiding Symptomatic Hypocalcemia. J Am Coll Surg 2010; 211 (01) 49-54
    CrossrefPubMedGoogle Scholar
  • 40 Walsh SR, Kumar B, Coveney EC. Serum Kalzium Slope Predicts Hypocalcaemia Following Thyroid Surgery. Int J Surg 2007; 5 (01) 41-44
    CrossrefPubMedGoogle Scholar
  • 41 Warren FM, Andersen PE, Wax MK. Intraoperative Parathyroid Hormone Levels in Thyroid and Parathyroid Surgery. Laryngoscope 2002; 112 (10) 1866-1870
    CrossrefPubMedGoogle Scholar
  • 42 Xing T, Hu Y, Wang B. et al. Role of Oral Kalzium Supplementation Alone or With Vitamin D in Preventing Post-Thyroidectomy Hypocalcaemia: A Meta-Analysis. Medicine (Baltimore) 2019; 98 (08) e14455
    CrossrefPubMedGoogle Scholar
  • 43 Youngwirth L, Benavidez J, Sippel R. et al. Parathyroid hormone deficiency after total thyroidectomy: incidence and time. J Surg Res 2010; 163: 69-71
    CrossrefPubMedGoogle Scholar